By Sharon Grady, PT, MS, RCS
In the intervention process, appropriate positioning and adaptive equipment should be introduced early. We think of normal development and what equipment we use to facilitate that process in children. Primarily, young children who are not walking or cannot walk for long distances use strollers for transportation. Commercial strollers are meant as a temporary means for transporting a child. If the child is under the age of 5, they are not considered adaptive equipment. Children with no developmental deficits are able to move and maneuver themselves in equipment and to let you know when they are tired or uncomfortable. Many of our children with developmental deficits are not able to communicate this discomfort. If they are unable to walk or move, they are often left in the stroller for longer periods of time. This can lead to early deformities and lack of appropriate interaction with their environment. Strollers without support are meant to be used only for emergency transportation or offer the convenience of easy storage and transport. These strollers do not adequately support the child, especially the trunk, and can affect their cardiopulmonary function. If a child requires long-term seating due to lack of development, ability to sit on their own, or independent mobility, they need appropriate equipment that will support them adequately and will help them with overall sensory motor development. To prevent deformities, this equipment should be able to maintain appropriate upright positioning for functional alignment and support. Also, it is important to make sure that good functional alignment is maintained for musculoskeletal growth and development.
The present thought is to get a child upright and moving as soon as he is able—or at the age that he would be bearing weight if he did not have deficits. Early weight-bearing is important to facilitate increased joint development and sensory awareness, and to help increase trunk control and strength that are imperative for sitting and standing activities. It also facilitates increased sensory motor awareness and perceptual awareness of being upright and interacting with one’s surroundings. Early intervention can prevent serious deformities and health problems in the future.
STROLLER VERSUS ADAPTIVE WHEELCHAIR
The use of a stroller versus an adaptive wheelchair for young children with neurological deficits has always been controversial. Usually, the main reason for using strollers is convenience. They are lightweight and easy to transport. When a child is younger than 5 years or small for his age, a regular stroller can be used for transportation purposes, but it cannot be considered as adaptive equipment. In order for a stroller to be paid for by an insurance company, it must qualify as adaptive equipment. Insurance companies base their approval for DME or adaptive equipment on medical necessity. The justification of medical necessity must indicate the purpose of the specialized equipment and why a regular stroller is not appropriate for this child. Most consideration for payment is based on the equipment lasting 3 to 5 years, or the length of time that the child will be able to use it. Some insurance companies are stating that they will pay for one wheelchair in a lifetime and an adaptive stroller can be considered a wheelchair. With these restrictions, we need to be more mindful of the appropriateness of the equipment that we are recommending for the child with special needs.
There are a variety of adaptive strollers on the market that allow for specific positioning adaptations to be put on them. The negative aspects of these strollers are the lack of adjustability for growth, and the inability to change the positioning of the child. Most strollers cannot be made to sit upright for appropriate posturing for feeding and fine motor activities. They do not have the ability to change their position in space. Also, the price of these adaptive strollers with a lot of ancillary equipment is very high. At this time, the child’s future must be considered as well as what equipment will be needed for him in all of his everyday activities, including transportation, education, feeding, and recreation. With this in mind, appropriate guidance should be given to the parents regarding the most cost-effective means of meeting all of their child’s developmental and everyday living needs. In addition, it is important to educate the parents on how the present equipment recommended will affect the child’s overall future development.
Among other considerations is the length of time each day the child will spend in the equipment, and the overall purpose for the equipment. As the child grows beyond the limitations of the standard toddler equipment, consideration must be given for an adaptive wheelchair. Preventing deformities at an early age is better than correcting them after they occur. Children are going to school at a younger age, and this means that they may have to ride on a bus. Presently, many schools are transporting children [with disabilities] in car seats depending on their size. Then, when they get to school, they are transported using a small wheelchair and are positioned appropriately in the classroom.
OVERALL DEVELOPMENTAL PROGRESS
Seating equipment for children should be recommended to enhance their overall developmental progress. The severity of the involvement of the child would determine the type of seating system to be recommended. Remember that a child’s skeletal system is very pliable, and deformities can occur rapidly. Bones grow in the direction the muscles are pulled. Therefore, positioning helps maintain good alignment as the child grows. Children with early intervention of appropriate positioning and equipment have fewer severe deformities when they are older. Also, many of these individuals are able to maintain their weight-bearing abilities, which significantly impacts their quality of care as adults. We must remember that what we are doing for a child at the age of 3 is going to impact where he will be when he is 25. I am a firm believer in early intervention for appropriate adaptive seating systems. It is the duty of the health professional to be aware of what is available for children and educate the parents on the appropriateness of the equipment for each child. Appropriate documentation will give support for funding.
EVALUATING A CHILD
When evaluating a child for an adaptive seating system, it is important to consider equipment that is going to enhance overall development. Appropriate seating improves his ability for head control and maintaining good functional alignment for spatial orientation. This will enhance his overall perceptual motor development. Also, appropriate alignment enhances his oral motor and feeding skills. An appropriate seating system is meant to provide good postural control to assist with normalization of tone and to give stability in the key points of control: head, trunk, and pelvis.
An adaptive seating system should be able to change the child’s position in space. This ability has been addressed in the new wheelchairs with a tilt in space system, which enables the system to be changed without changing the child’s sitting posture or positioning. Also, it relieves pressure to prevent skin breakdown and decreases fatigue when the child is in the equipment for longer periods of time. This equipment should allow for growth as well as have interchangeable components that can be altered as the child’s therapeutic needs change.
If an adaptive seating system is needed, then it is necessary to have it work in all areas of the child’s daily life. Appropriate support so that he is posturally secure will enhance his ability to use his upper extremities for fine motor activities, as well as independent feeding. If a child does not have enough motor control to maintain himself upright, then he must be given an appropriate external support system to enable him to sit upright. Many of the new seating systems break down for easy transport in a family car. Some of the adaptive seating systems for small children are able to be used as car seats and have been crash tested.
These same children need to be positioned upright for weight-bearing on their lower extremities at an early age. I recommend that it occur prior to the age of 1 year if the child is medically stable. This means giving appropriate support so that weight-bearing is accomplished in the same alignment as the child would be in if they were standing independently. Weight-bearing enhances joint development, especially in the lower extremities. Joint compression through weight-bearing also enhances muscle development, which is especially evident with the postural-support muscles of the trunk and hips. Early standing helps prevent structural deformities. When choosing standing equipment, it is important that we look at equipment that allows adjustments for growth in all directions as well as adapts to the child’s neurological and developmental changes.
At the same time that standing equipment is introduced, it is important to think of beginning mobility. The saying goes that a child learns to move to move to learn. Children learn by exploring their environment, and appropriate mobility equipment gives the child that dynamic sense for increasing his musculoskeletal development. Again, it is important that mobility equipment such as walkers maintain the child in good functional alignment and give him the ability to move.
One of the best pieces of equipment that I have seen for this is a posterior-support, weight-relieving gait trainer. This equipment gives good trunk and pelvic support to maintain the child upright so that the movement and weight-bearing facilitate increased trunk extension and trunk strength. Also, it is a spring-assist weight-bearing device that helps the child come upright when initiating weight-bearing on his lower extremities. It is adjustable for the angle that assists the child with moving forward. Make sure that the mobility device is emulating a normal gait pattern in the child.
It is important for the child to understand that he can move without all of the exertion needed when he attempts to crawl. Early mobility enhances a young child’s overall sensory motor development. It gives him the appropriate visual perceptual awareness of his environment and increases his perceptual awareness of movement in space, which enhances his independent exploration. Also, a mobility device in the home and at school is a therapeutic tool that can be used in place of a therapist’s hands and as a precursor for independent ambulation with a walker or complete independence. This gives a child more time to be working on lower extremity strengthening and endurance with walking activities. It increases his postural stability and security with movement in space, which is much different than static standing. Early mobility and weight-bearing not only increase musculoskeletal development, but also facilitate more normal cardiopulmonary function, digestion, and bowel elimination.
Appropriate mobility equipment enables the special needs child to be integrated into a family by being a part of its day-to-day activities. In the past, equipment was not available for a child with motor deficits to be positioned upright for beginning mobility. The only way a child could stand was with a parent or therapist giving support. Due to the fear of falling, the child’s tone would increase, thereby decreasing his potential for ambulation. With more equipment available for walking, a child gains confidence as well as strength, which increases his potential for independent ambulation with or without assistive devices. With increased strength, the child’s potential for earlier independent ambulation increases.
With a decrease in funding for individualized therapy treatments for children, appropriate equipment enhances development and can be a replacement for therapy. Appropriate consultation is necessary to make sure that proper equipment is used by the child. The important thing to remember is that earlier intervention with appropriate equipment will enhance the child’s potential for mobility in his environment. Appropriate documentation by the therapist can provide medical justification for the purchase of equipment. I have seen evidence that using equipment early has significantly decreased structural deformities in the older handicapped individual. This equipment has also, at times, made it possible for a family to keep their disabled child at home. It is especially important for the pediatric therapist and DME dealer to keep up to date on available equipment so that their recommendations will meet the child’s global developmental needs.
Sharon Grady, PT, MS, RCS, is a physical therapist who specializes in working with infants. She is based in Fountain Valley, Calif.
